=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164711644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOOSHA MEDICAL CENTER P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2011
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4438 N MILWAUKEE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60630-3743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-794-2100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4438 N MILWAUKEE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60630-3743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-794-2100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EBRAHIM GHODSIZADEH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 773-794-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0360856071
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------